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External Snapping Hip Syndrome

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External Snapping Hip Syndrome J Korean Soc Radiol 2010 ; 62 : 185 - 190 External Snapping Hip Syndrome: Emphasis on the MR Imaging1 Jung Eun Choi, M.D., Mi Sook Sung, M.D.2, Ki Haeng Lee, M.D.3, Bae Young Lee, M.D., Jeong Mi Park, M.D.4, Jee Young Kim, M.D.5, Won Jong Yoo, M.D.2, Hyun Wook Lim, M.D.2, Myung Hee Chung, M.D.2 Purpose: The aim of this study is to evaluate the MR imaging features of patients with external snapping hip syndrome. Materials and Methods: We retrospectively reviewed 63 hip MR images. The images were analyzed according to the thickness and contour of the iliotibial band and the gluteus maximus, the presence of bone marrow edema, bursitis, joint effusion and oth- er associated findings. Results: The MR imaging of 22 hips with snapping hip syndrome depicted the causes of external snapping hip syndrome in twenty cases (90%). The MR imaging features of the snapping hip included thickening of the iliotibial band in twelve cases (55%) and/or thickening of the anterior band of the gluteus maximus in nineteen (86%), and a wavy contour of the iliotibial band or the anterior band of the gluteus maximus in ten cases (45%). These findings show a significant p value (<0.01). Conclusion: The majority of patients with snapping hip syndrome revealed thickening of the iliotibial band, thickening of the anterior band of the gluteus maximus and wavy contour of the those structures on MR imaging. Index words : Hip Joint Magnetic Resonance Imaging Snapping hip syndrome is characterized by an audible rectly listening to the clicking sounds that are generated snapping hip on flexion and extension of the hip during during the repeated flexion and extension of the hip or exercise or with the normal activities of daily living (1). by palpating abnormal movement, and tenography (2), Snapping hip syndrome is generally diagnosed by di- sonography and/or MR imaging have occasionally been used. The sonographic findings of the internal and exter- 1Department of Radiology, The Catholic University of Korea, St. Paul’s nal types of snapping hip syndrome had recently been Hospital, Seoul, Korea reported (3-5). 2Department of Radiology, The Catholic University of Korea, Bucheon St. Mary’s Hospital, Bucheon, Korea In this current study, we described the MR imaging 3Department of Orthopedic Surgery, The Catholic University of Korea, findings of external snapping hip syndrome in 16 pa- Bucheon St. Mary’s Hospital, Bucheon, Korea 4Department of Radiology, The Catholic University of Korea, St. Mary’s tients with 22 snapping hips. Hospital, Seoul, Korea 5Department of Radiology, The Catholic University of Korea, St. Vincent’s Hospital, Suwon, Korea. Materials and Methods Received July 23, 2009 ; Accepted November 10, 2009 Address reprint requests to : Mi Sook Sung, M.D., Department of Radiology, The Catholic University of Korea, College of Medicine, Bucheon We retrospectively reviewed the MR images of 16 pa- St. Mary’s Hospital, Sosa-dong, Wonmi-gu, Kynggi-do 420-717, Korea. tients with 22 snapping hips, and we obtained and as- Tel. 82-32-340-2184 Fax. 82-32-340-2187 E-mail: [email protected] sessed the electronic charts of these patients at outpa- ─ 185 ─ Jung Eun Choi, et al : External Snapping Hip Syndrome tient orthopedic clinics from 1998 to 2003 and all these tions. The MR image of the unaffected hip was also ob- patients had the clinical diagnosis of external snapping tained: the T2-weighted axial image with a 180 mm hip syndrome. The diagnosis of snapping hip syndrome FOV and a 330 mm FOV. had been made by directly listening to the clicking The MR images of snapping hip syndrome were eval- sounds during physical examination or by palpation by uated by the thickness and contour of the iliotibial band orthopedic surgeons. The clicking sound was assessed and the gluteus maximus, the bone marrow of the hip with the patient lying down in the lateral incumbent po- joint and other associated pathology of the hip joint like sition with the affected hip joint on the top, the knee a labral tear, the presence of loose bodies and bursal ab- joint was extended under the condition that a sand bag normalities. The thickness of the iliotibial band and the was placed the opposite pelvis and so the affected ex- anterior border of the gluteus maximus were measured tremity undergoes varus while the tension of the iliotib- separately at the level of the femoral greater trochanter ial band was maintained when repeating the flexion and on the axial T1 weighted image. Both hips were com- extension of the hip joint. pared on the axial and coronal images with a 330 mm The control group was composed of 21 age matched FOV, and the structure of the affected hip was observed patients (41 hips) with unilateral hip pain and who un- in more detail on the axial image with a 180 mm FOV. derwent hip MR. These patients were randomly select- Abnormality of the bone marrow, the presence or ab- ed from a larger number of patients who underwent sence of bone marrow edema (increased signal intensity MRI from 1998 to 2003 and who were without evidence on the T2-weighted image), joint effusion and the pres- of clinically proven snapping hip, and then the hips ence or absence of bursitis were evaluated on the T2- were divided into two groups of hips: 1) the painful weighted images with or without fat suppression. Two symptomatic side of the hips (20 hips) and 2) the asymp- musculoskeletal radiologists analyzed the images and tomatic side of the hips (21 hips). the clinical findings. Our institutional review boards didn’t require their Statistical analysis was done using chi-square tests and approval or informed patient consent for retrospective independent sample T tests. A p value of less than 0.01 study of the case records and MR studies. was considered statistically significant. All the patients underwent MR imaging (1.5T system, Philips, Gyroscan NT, Eindhoven, The Netherlands.) of Results the hip. The imaging sequences include the coronal T2- weighted image (TR/TE: 3800 ms/ 90 ms), the axial T1- The mean age of the patients with snapping hip syn- weighted image (TR/TE: 500 ms/ 20 ms), the axial fat sat- drome was 38 years (range: 15 to 61 years; 11 men and 5 urated T2-weighted image and the axial T2-weighted women) and the ages of the control group ranged from image of the hip. The imaging parameters included a 19 to 61 years (mean: 39 years; 15 men and 6 women). 180 mm field of view (FOV), 4 mm slice thickness, a 0.5 Six cases exhibited bilateral hip snapping. The mean du- mm gap, a 256×196 matrix and two or three excita- ration of the symptom was 42 months (range: 14 to 70 A B Fig. 1. A 56-years-old man with left snapping hip syndrome. Marked thickening of the iliotibial band (arrow) can be nicely noted on the T2-weighted MR images with a small FOV (180 mm) (A) and a large FOV (330 mm) (B), as compared with the iliotibial band of the right hip. ─ 186 ─ J Korean Soc Radiol 2010 ; 62 : 185 - 190 months). All the patients with snapping hip syndrome (2 hips) and idiopathic (3 hips); 1 hip on the sympto- displayed audible snapping, which was well correlated matic side was excluded from the analysis due to being with hip pain. None of the cases had a past history of in a post-operative state after total hip replacement. fracture or surgery in the hip joint area. The MR imaging features of snapping hip syndrome in- The causes of the hip pain for the control group were cluded thickening of the iliotibial band and/or thickening confirmed as follows: avascular necrosis (5 hips), labral of the anterior band of the gluteus maximus in nineteen tear (7 hips), tendinitis (1 hip), osteitis (2 hips), synovitis hips (86%) (Figs. 1-3), and wavy contour of the iliotibial Table 1. Comparison between the MR Imaging Features of the Snapping Hip Syndrome Group and the Control Group Thickening of the Wavy Fibrosis Marrow Joint Trochanteric ITB / GMx Contour edema effusion bursitis Snapping hip 12 (55%) 19 (86%) 10 (45%) 12 (55%) 1 (4%)0 10 (45%) 2 (9%)0 Syndrome (n=22) The control group with 0 (0%) 1 (5%) 0 (0%) 09 (45%) 3 (15%) 08 (40%) 4 (20%) the symptomatic side of the hips (n=20) The control group with 1 (4%) 1 (4%) 0 (0%) 06 (28%) 1 (4%)006 (28%) 2 (9%)0 the asymptomatic side of the hips (n=21) P <0.01 <0.01 <0.01 0.221 0.155 0.511 0.494 Note: ITB; iliotibial band, G Mx; gluteus maximus Fig. 2. A-24-years old man with snap- ping hip syndrome of both hips. The anterior border of the gluteus maximus of the right hip is thickened (arrow) (A). The left iliotibial band (double arrow) is thicker than that of right iliotibial band on the T2-weighted MR images (B). AB Fig. 3. A 48-years-old man with left snapping hip syndrome. (A) Note the normal finding of the right iliotibial band (arrow) on the axi- al T2-weighted image. The 2 musculo- tendinous attachments of the iliotibial band consist of the anterior tensor fas- cia lata and the posterior gluteus max- imus (double arrow). (B) The T2- weighted MR images (FOV 180 mm) show thickening of the left anterior border of the gluteus maximus (arrow head). AB ─ 187 ─ Jung Eun Choi, et al : External Snapping Hip Syndrome band or the anterior band of the gluteus maximus in ten border of the gluteus maximus was seen as low signal hips (45%) (Fig.
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